State guide
New York
Pick the kind of plan you have to see who to call first. New York can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
New York usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call New York State Department of Financial Services (DFS). See the at-a-glance box.
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Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in New York.
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Medicare
Health Insurance Information Counseling and Assistance Program (HIICAP), New York State Office for the Aging gives free counseling. Or call 1-800-MEDICARE.
The short version for New York
New York has one of the most complete external appeal systems in the country: you apply to the state Department of Financial Services, which assigns an independent reviewer, and its public database lists thousands of past decisions by health plan. Roughly half of external appeals in the most recent data went at least partly in the patient's or provider's favor. Free one-on-one help comes from Community Health Advocates, and the state Attorney General runs a health care helpline that works on denials.
At a glance: independent review for plans New York regulates
- Main regulator
- New York State Department of Financial Services (DFS) · (800) 342-3736
- Independent review
- A state process (External appeal (reviewed by an independent external appeal agent))
- Deadline to request it
- 4 months after the final adverse determination from your insurer's internal appeal (or after the insurer waives the internal appeal). Providers appealing on their own behalf have 60 days.
- Cost
- Your health plan may charge up to $25 per appeal, no more than $75 in a plan year; the fee is waived for Medicaid, Child Health Plus and Family Health Plus members or if it would cause hardship, and is refunded if your appeal is overturned.
- Decision time
- 30 days (72 hours for a non-formulary drug request); fast track: 72 hours (24 hours for a non-formulary drug request)
Who regulates health plans
Look at your health insurance ID card. If it says "fully insured", your coverage follows New York law and the state external appeal applies. If it does not, ask your insurer or employer: self-funded employer plans (which many large employers use) and out-of-state policies are outside New York's rules.
- New York State Department of Financial Services (DFS)
Fully insured health plans bought in New York (individual and employer group policies from insurers and health maintenance organizations (HMOs)), plus the New York State Empire Plan and the State Student Employee Health Plan for surprise bills. It does not regulate self-funded employer plans (where the employer pays claims itself), out-of-state policies, or Medicare.
- New York State Department of Health (Managed Care Complaint Unit)
Quality-of-care and service complaints about state-certified managed care plans, including Medicaid managed care, Child Health Plus and managed long-term care plans; also runs the state Medicaid program.
Independent (external) review
- Process
- A state process. Run by New York State Department of Financial Services, which assigns each case to an independent external appeal agent.
- Where you file
- regulator
- How
- Apply to the Department of Financial Services (not to your insurer), either online through the DFS Portal (choose "DFS Portal Login") or by sending the paper application to Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210, or by fax to (800) 332-2729. Your doctor may need to sign an attestation form for some appeal types. Questions and help with the application: (800) 400-8882; for an expedited appeal sent by fax, use (888) 990-3991.
- Which denials qualify
- Denials because a service was found not medically necessary, experimental or investigational, a clinical trial, a rare disease treatment, an out-of-network service or referral (when the plan says an in-network option is available), a formulary exception, or a step therapy override refusal; plus No Surprises Act questions such as whether care was an emergency, whether a bill is a surprise bill, correct cost-sharing, and certain coding disputes. Denials that a benefit is simply not covered by your contract go through the plan's grievance process and a DFS complaint instead.
- Appeal to the plan first?
- Yes. You must finish your plan's internal appeal or the plan must waive it. A second-level internal appeal, if your plan offers one, is optional and does not extend the 4 months. For expedited cases you may request the internal and external appeals at the same time, and an internal appeal is generally not required for a formulary exception.
- Published results
- DFS's 2026 Consumer Guide (calendar year 2025 data) reports external appeals decided for the member or provider, including in part, in 57.09% of 268 HMO cases and 48.79% of 2,265 cases for preferred provider and exclusive provider organization plans. It excludes Medicare, Medicaid, Essential Plan, Child Health Plus and self-insured plans. Source
Free help in New York
- Community Health Advocates (program of the Community Service Society of New York)
Free helpline (Monday to Friday, 9 a.m. to 4 p.m.) and local advocates who explain denials and help with appeals, with do-it-yourself appeal letter packets by denial reason, for any kind of coverage; the Centers for Medicare & Medicaid Services lists it as New York's consumer assistance program.
Phone: (888) 614-5400
- New York State Attorney General Health Care Bureau helpline
An advocate takes your complaint about denied treatment, tests, devices or prescriptions, out-of-network charges, missing prior authorization, or improper balance bills, and contacts your plan or provider or refers you to the right agency.
Phone: 1-800-428-9071
Medicare and Medicaid in New York
- Medicare counseling
- Health Insurance Information Counseling and Assistance Program (HIICAP), New York State Office for the Aging · 1-800-701-0501 . Free help with Medicare appeals.
- Medicaid agency
- New York State Department of Health (Medicaid); fair hearings are run by the Office of Temporary and Disability Assistance, Office of Administrative Hearings
- Fair hearing deadline
- Medicaid managed care: 120 calendar days from the date of your plan's final appeal decision. Other Medicaid denials: 60 days from the date of the notice. Your notice states the deadline that applies to you.
- Good to know
- If you are in a Medicaid managed care plan, you must first appeal to the plan (60 days from the date of its denial notice), and only then can you ask for a fair hearing. You may also have a right to a New York State external appeal; the state's Independent Consumer Advocacy Network suggests doing the external appeal first because it is usually faster, while the fair hearing decision is the final answer if you request both. To request a hearing: call 1-800-342-3334 or use the form at otda.ny.gov/hearings. A fast-track hearing can be requested if waiting would seriously risk your health. Managed Care Complaint line: 1-800-206-8125.
State laws that can help
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Step therapy. Your plan must decide a step therapy override request within 72 hours (24 hours if your health is in serious jeopardy) when your doctor shows the required drug is harmful, expected to be ineffective, already failed, or you are stable on your current drug, and a missed deadline counts as a granted override.
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Denial notice. Plans must tell you the medical reason for a denial, that medical personnel made the decision, how and by when to appeal, and about your right to an independent external appeal.
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Surprise billing. For fully insured plans, out-of-network providers at in-network hospitals and surgical centers, and out-of-network emergency care, cannot bill you more than your in-network cost-sharing, and you can use the state's independent dispute resolution process.
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Mental health parity. Insurers must give mental health and substance use care a similar level of benefits as medical and surgical care, cannot set annual or lifetime limits on it, and cannot require preauthorization for in-network, state-licensed inpatient or outpatient substance use treatment or for opioid treatment medications.
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External review. New York's external appeal is unusually broad, covering medical necessity, experimental treatment, out-of-network, formulary, step therapy and No Surprises Act disputes, and the reviewer's decision binds your plan.
Sources and what we could not confirm
- New York State Department of Financial Services: New York State External Appeal
- New York State Department of Financial Services: Healthcare in New York
- New York State Department of Financial Services: Mental Health and Substance Use Disorder
- New York State Department of Financial Services: Surprise Medical Bills
- New York State Department of Financial Services: File a Complaint
- New York State Department of Financial Services: Questions and Answers on step therapy legislation
- New York State Department of Financial Services: 2026 Consumer Guide to Health Insurers
- New York State Department of Financial Services: External Appeals Searchable Archive
- New York State Department of Health: Complaints and Appeals, Managed Care
- New York State Department of Health: Guidance for Required Changes to Final Adverse Determination Notices (Medicaid managed care fair hearing)
- Office of Temporary and Disability Assistance: Fair Hearings FAQ
- Independent Consumer Advocacy Network: Appeals in Medicaid Managed Care Plans
- Community Health Advocates: Contact Us
- Centers for Medicare & Medicaid Services: New York Consumer Assistance
- New York State Attorney General: Health care helpline
- New York State Office for the Aging: HIICAP
- State Health Insurance Assistance Programs: New York
- New York State Senate: Insurance Law section 4903
Not confirmed (13)
- How to file for independent review. the Department of Financial Services page hides its email addresses; the hard-copy submission email could not be read, so only mail, fax and phone are given. The portal login page was not opened past the chooser (an account is required).
- The state regulators. (800) 342-3736 is printed on the Department's health insurance page and on the Department of Health complaint chart; the Department's complaint page itself prints no phone number. The Department of Health chart also lists 1-212-480-6400 for New York City callers.
- The state regulators. the Department of Health is listed from its complaint chart; its quality-of-care role for HMOs comes from the earlier research file and the chart, not from a full read of the agency's pages.
- The Medicaid fair hearing deadline. the 120-day figure comes from the Department of Health's own guidance on notices and a federal-rule FAQ; the 60-day figure for non-managed-care Medicaid is from the Office of Temporary and Disability Assistance FAQ, which says to check the time limit printed on your notice.
- Notes on Medicaid appeals. the deadline to keep benefits while you appeal (aid continuing) was not confirmed; check your notice. The advice to file the external appeal first is from the Independent Consumer Advocacy Network (a nonprofit), not the state.
- Notes on Medicaid appeals. the Independent Consumer Advocacy Network page says automatic fair hearing requests for some plans end January 1, 2026; the current status was not checked.
- Free consumer help programs. the Community Health Advocates page does not itself say the state designated it; the designation is from the Centers for Medicare & Medicaid Services list and earlier research, and funding was not verified.
- Free consumer help programs. the Attorney General's online complaint form address was not retrieved; the helpline page lists an online complaint option.
- Not confirmed. stateLaws (denial-notice, external-review) — the citations are the article-level Insurance Law and Public Health Law references; the statute text of each sub-section was not read, and the Department's page summarizes rather than quotes them.
- Not confirmed. stateLaws (mental-health-parity) — the Department's page cites no statute; the parity rules are summarized from the page only.
- Not confirmed. stateLaws (surprise-billing) — the Financial Services Law article 6 citation is from the Department's hub page; the surprise bills page itself cites no statute.
- Not confirmed. stateLaws (prior-authorization, ai-in-utilization-review, gold-card) — no New York law on these topics was researched or confirmed. The Insurance Law section 4903 text found online shows changes marked effective January 1, 2027, which were not analyzed.
- The Medicare counseling program's phone number. the Department of Financial Services Medicare page prints both (800) 701-0501 and (800) 342-9871 (to be directed to a local office); the Office for the Aging number is used.